HomeMy WebLinkAbout1395A WORKERS'COMPENSATION DECLARATION �. APP`ICATION FOR PERIVIIT, �
I hereby�affirm ihal I have a�cerlificale of consent to self �
Insure,or a certifica�e of Workers'Compensarion Insurance, � . HEATING - VENTILATING - AIR CONDITIONING
�r cer i(ied copy thereof(Sec.3 ,lob. .) 76A764C � � � .
�� � ��/ 7 CE-818(REV.IO/91)'
V^of+c� .1 a ��Compon COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Certified copy Is hereby furnished. . � ��
� Cer�ified mpy ts filed with the couNy building inspao- FOR APPLICANT TO FILL IN suitoiNG
tiondepo�ime ADDRESS (, � �00 / G��
�/ �( � �ENHP L n� (PRINT OR TYPE ONIY) �
Da1e LLl—App i[ont � ��"�'��� NO. TVCE OF AP7LIANCE OR EQUIPMENT � iEE `�`ITM ����
� r�
� CERTIFICATE Of EXEMPTION FROM WORKERS' � - NenREST . ,
COMPENSATION INSURANCE � � � � CRO55 ST. '
[Tl�ls socffon naod nof bo complofad if fho work fnvolved by ABSORPTION UNIT,BtU DISiRICE NO. PROCFSSFD BY
the perm(f ts for one hundred dollors(SI00)or less.) � � �Q .
I certify thot in 1he performante of}he work for which ihis AIR HAN�LING UNIT,CFM
pe�mi�is issued,I shall not employ any peison in ony manner
so,as to become subject to tha Workers'Compensolion LowS. BOILER,BTU APPROVAlS DATE INSo �OR'S SIGNANRE
Date Appli[ant I COMPRESSOR,BTU �0 M f ROUGH
NOTICE TO APPLICANT: If, after moking Ihis Certifi[ate of VENTItATION SYSTEM F�NA� '�.`i�U�
Exemption, you should become subject to the Warkers'
Compe�so��on provisions oi the Lobor Code,you must forih- _ EyAPORATIVE[OOtER ' VALIDATION
wilh comply with such provisions or this permif shall be ' �
deemed revoked. �- - FURNACE:. FAU aVIN !�
. LICENSED CONTRACTORS DECLARATION . � FLOOR BTV (J
I hereby offirm thot i am licensed under provisions of Chapter 9 HEATER: SUSVENDED UNIT_ �
'(commencing with Seclion 7000)of Division 3 of fhe Business WAtI , �
and Frofessions Code,ond my liten5e is in fuU force ond ef ett. . ' . . . . . . p, ..
License Numbe�� Ss� Lla Class�'� -- � , � V -
�'F�eA. �,u�Qc S' � �� �,� .. .. 1 3 v.5 a �
ContraUor pote-1=l,/=�-� � • �• . �• •g � -
❑ I om ezempt under Sec. � . . . � . � . .3 Q g Q �
. Plan check fee ,�
8.8P.C.for this reason� � � �3 Q 5 p c=i Z
PERMIT ISSUING FEE S '•� —
Date:
������� TOTAL FEE 0 Z 1 7—S 5
S'anelure�!_�_n ,
OWNER�BUIIDER DECLARATION PLAN CHECK APPLIG4NT . .
I here6y affirm thot I om exempt from the Contracior's license . �
Law for the(ollowing reason(Sectian 7031.5, Business ond . NAME - . .
Professions Code): �
❑ 1, as owner of fhe prope��y, or my employee5 wilh AD�RESS .
- wages as iheir sole compensotion,will do the work and CITV � TEL.NO. �
the struclure is not inlended or oifered for sale(Seclion
7044,Business and Professions Code). OWNER . .
❑ I,as owner of ihe properly,am exdosively controcting MA" • �l �
wilh licensed conlraclors 10 con5�r�ct Ihe projecf($ec- AD�RESS O 6f.3'JeRtaart f `� � � ' � �
- tion 7044,Business and Professions Code). •
CONSTRUCTION LENDING AGENCY � CITY � � iEL N .- -- � .
I hereby oifirm�hat ihere is a construciion lending agency for �
the performonce of the work for which Ihis permit is issued COMRACTO '-� '- -�
(Sec.3097,Civ.C.). . E � �.LG l� .._... .. ..- --. . . ,
ADDRES .s--� . ... . ... .. _ . ... . � . . _ .
lender i Name
CITY ��� / TEL NO. _ . . . .. .. .. _. .
Lender i Address � � �
STATE LIC. ,
I tertify thof I hove read this appli[otion and state Ihat the LICENSE NO. ,S' �CtA55�� - - --��- --� -� --� � �� � . ��� �
above information is correct.I agree to comply with all CovNy . ' � � -
ordinances and Stote lows rela�ing to building construction, , , - ' .
and h y horize represenlatives af this County to enter -.. . . . ... . . . .... . . - .'.. ... ... .`... .. .. . .. � � �
upo t �ve-memloned properry for insp cti po�oses. SEE REVERSE FOR EXPLANATORY LANGUAGE
t ✓
Signorure of Applicant Age� Dob . .... .. .� .. .... ..._.. . '"-"'......._
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